Neuroimaging outcomes in suspected papilledema

Papilledema due to elevated intracranial pressure may indicate life-threatening conditions such as intracranial mass lesions or cerebral sino-venous thrombosis. This bicentric retrospective cohort study evaluated neuroimaging outcomes and clinical predictors in adults presenting with suspected papilledema to emergency departments between 2009 and 2022. Diagnostic outcomes were categorized as confirmed papilledema (due to idiopathic intracranial hypertension, space-occupying lesions, hydrocephalus or secondary intracranial causes) or papilledema ruled out. Clinical features, visual acuity, and frequency of focal neurological deficits were compared between groups. Diagnostic yield and number needed to scan (NNS) for CT and MRI were calculated, and univariable logistic regression was performed to identify predictors of secondary intracranial causes. Among 225 patients (mean age 43.0 ± 16.8 years; 57% female), papilledema was confirmed in 124 (55%), including 44 (35.5%) with secondary intracranial causes. Papilledema was excluded in 73 patients (32.4%). Primary CT and MRI identified secondary pathology in 13.3% (NNS 7.5) and 16.7% (NNS 6) of patients, respectively. Diplopia, nausea/vomiting, and focal neurological deficits were associated with secondary causes but were not consistently present. Secondary intracranial pathology is common in suspected papilledema. Given the limited discriminatory value of clinical features, timely neuroimaging should be performed in the diagnostic evaluation.